Wednesday, 3 April 2013

Day 132: Dependence

If you are reading this blog, it is likely that over your lifetime you have taken part in or witnessed heated discussions about the use of the word "addiction" when talking about cigarettes and smoking.

If so, you can imagine what today's hearing was like at the Montreal tobacco trials, as lawyers for the defendant tobacco companies completed their cross examination of the plaintiffs' expert witness in addiction, Dr. Juan Negrete.

There was very little new ground gone over today. A lot of time was spent on similar points to those raised  in the initial rounds of the cross-examination last week, i.e. - tobacco is addictive only because the definition of addiction was changed, the clinical evaluation of tobacco addiction is suspect, most smokers can quit and therefore should not really be considered addictive, etc. etc.

The lawyers seeking to get Dr. Negrete's agreement to their point of view today were Sonia Bjorkquist (for Imperial Tobacco) and Guy Pratte (for JTI-Macdonald).

Dr. Negrete had little apparent patience for their questions, their framing of events or their characterization of the issues - and he frequently let his impatience show. The lawyers' also showed their impatience with the witness' answers, frequently chastising the nature of his replies. ("Wait for me to finish my question," "You did not give me an answer.")

On neither style nor content was it a pleasant day. 

A sketchy tour of dependence/addiction

Ms. Bjorquist arrived at this trial only last week, and today was her first substantive intervention. Like most of the younger lawyers on the defence teams, she is well mannered and overtly deferential. 

It was in a somewhat mannered way that she worked her way through a binder full of questions, checking items off with a purple pen as she went along, pausing on a topic seemingly to make sure she had received the answer she felt she was due from the witness.

She spent much of her time tracing the evolution of terms to describe what is commonly referred to as addiction, and the application of those concepts to tobacco or nicotine.

She started with a document that was likely written before her mother was born -- a 1950 World Health Organization report of an Exert Committee "Drugs Liable to Produce Addiction". (Exhibit 1470.7), and worked her way through a 1964 report of a similar WHO committee (Exhibit 1470.8), the U.S. Surgeon-General's Reports of 1964 (Exhibit 601-1964), the 1964 report of Health and Welfare Canada on "The Cigarette Smoking Habit" (Exhibit 20060) - and even the LeDain Commission report on on the non-medical use of drugs.
1964 US Surgeon General Report

But there was no history of science to this presentation -- nor any insights into the overlap of these varying statements of scientific consensus or the back story to some events. 

Had everyone forgotten that only a few months ago Robert Proctor had written in his expert report (Exhibit  1238): "The chapter characterizing smoking as a "habit" rather than an "addiction" in the 1964 Surgeon General's report was written by Maurice Seevers, a pharmacologist who had earlier worked as a consultant for the American Tobacco Company, makers of  Lucky Strike cigarettes. It was Seevers who managed to have the Surgeon General's Advisory Committee adopt this weaker notion of cigarette smoking as merely as a "habit" ..."

(A readable explanation of events can be found in a paper by Sara Mars and Pam Ling).

Eventually, Ms. Bjorquist worked her way up to 1988, and the Surgeon General's report on addiction.

It was only one of several ironies of the day to see the conclusions of the 1988 report flashed on the screens around the courtroom. The statements that the industry once disavowed - that nicotine was an addiction like heroine or cocaine - were being presented by the industry lawyers in their defense against a suit based on addiction. Go figure.

1988 US Surgeon General's Report
 "This was the first report from a major organization to use the term addiction," she stated - asking Dr. Negrete to agree. He struggled to communicate that the word "addiction" and "dependence" were used interchangeably in this report and that those terms were a distinction without a difference. No matter how often he said it, she appeared not to understand.

(Had his testimony been in French, as it was originally proposed, the conversation would have sounded much different - as the terms dépendance, tabagisme and nicotinisme have had a separate evolution).

As she moved through her final set of questions, I began to wonder if she perhaps had never known a smoker. "Smokers can decide to work and go outside... they can decide to quit…. to succeed in smoking a smoker has to decide they no longer want to smoke, right?"

Dr. Negrete did not respond to her repeated reference to "decisions" and "willpower", but instead added a counterpoint to her perspective. "Of all the drug dependencies, it is the one that is the most available and accessible to the consumer." ''People quit smoking every day based on their own circumstances yes. and they relapse too."

The "Health Canada" defense 

Guy Pratte (for JTI-Macdonald) moved to the front desk and began asking questions well before lunch-time, and until close to the end of the day, he sustained an unusually forceful tone in his questions to Dr. Negrete. (This is a marked contrast to his style of questionning Jack Siemiatycki only two weeks ago).

He brought the federal government back into the trial, using several documents to suggest that the federal view and research was supportive of the industry's position. 

He pointed to Health Canada using the term "habit forming" some 20 years after Dr. Negrete said it had fallen out of use. He used federal government statistics to show that smoking rates among Quebecers had fallen from 30% to 20% between 1999 and 2005? "Hundreds of thousands of people have quit smoking," the lawyer asserted. 

He cited Health Canada's health promotion messages (You will be able to stop smoking for good!) and mandatory cigarette warning messages (You can quit. We can Help) as proof that all smokers can quit. 

When asked "Is that statement true or false?" Dr. Negrete again struggled to find an appropriate answer to a slippery question. "It is true as a general rule, but doesn’t take account of many things..the goal of the statement sit so encourage people to try."

"You can quit. We can help"  --  "Isn't that another affirmation that everyone can quit? Every one can quit! That’s what Health Canada tells smokers."

"In ideal circumstances, which do not exist for everyone," replied Dr. Negrete, pointing back to the web-site reference to "the right combination of practice, determination and support."

Over the afternoon, Mr. Pratte turned to the studies that had been used as a basis of Dr. Negrete's conclusions about the prevalence of dependence among smokers, and other studies looking at short and long term smoking rates. As Mr. Potter had done last week, he pushed the witness (mostly unsuccessfully) to admit that the studies he relied on were not based on the general population, but on people who were likely to be more dependent. 

The testiness between witness and lawyers which continued throughout the day made for a tiring and tiresome exercise. By the time Philippe Trudel had the opportunity to ask his final set of questions to the witness, I think everyone wanted to go home.

Mr. Trudel asked the psychiatrist a very short round of questions. He wanted to know how important it had been to do an examination of a patient before prescribing stop-smoking medications, and whether it was necessary to be a psychiatrist in order to be able to prescribe treatment for nicotine dependence. He asked the witness to reflect on the Health Canada smoking statistics that showed a stable proportion of smokers who reported smoking a cigarette within 30 minutes of waking. (Dr. Negrete had testified this was a marker of a more severe level of dependence)

At 4:15, Dr. Negrete was thanked and invited to step down. 

The discussion of nicotine addiction is far from over, however. The industry has several defense experts lined up and ready to testify. But when?

Tomorrow, Mr. Jacques LaRivière will be in the court "for the purposes of removing the 2M" designation from documents.